Make: ______________________ Model: ______________________________ Year: __________

SOLD TO:

SHIP TO: (if different from Sold To)

Name:

Name:

Address:

Address:

City:

City:

State:                                            Zip:

State:                                            Zip:

Daytime Phone: (         )

Daytime Phone: (         )

QTY.

Fabric Color

Description

Price/Ea.

Extension

Check or Money Order Enclosed

Charge to my:

MasterCard VISA      AMEX

Contact Name: _____________________ Purchase Order #_______________________

For overnight shipments, call for quote.